Comment
The Trifecta valve has demonstrated excellent hemodynamic performance,
especially for patients with a small aortic annulus, and acceptable
durability within the early postoperative period (3). But, according to
a recent study, the Trifecta valve had no hemodynamic superiority in
maintaining a large valve orifice area over mid- and long-term periods
while calcification and leaflet tear parameters were inferior to CEP
(4). Some case reports on early leaflet tears in Trifecta valves (5,6)
reported that a single leaflet tear may be causative for mild heart
failure but two or more tears risks severe and catastrophic heart
failure, necessitating an emergency operation (7). Similarly, both of
our cases presented with acute dyspnea symptoms linked to rapid ruptures
at two leaflets, with the second case especially requiring resuscitation
and rapid operation.
Hemodynamics are the crucial aspect of these early leaflet tears.
Vriesendorp et al. conducted a 600 million cycle test in vitro with the
Trifecta valve as an externally mounted valve and the CEP and Avalus
(Medtronic, Minneapolis, MN, USA) valves as internally mounted (8). Of
note, the Trifecta valve experienced leaflet tearing at 500 million
cycles, corresponding to 10 years in vivo. High-speed camera analysis
revealed that leaflets of externally mounted valves wrap around the
stent when closing and this motion causes tissue abrasion and eventual
tearing whereas leaflets of internally mounted valves are forced against
the opposite leaflets, reducing tensile force from the stent. This
finding may explain the higher freedom from reintervention seen with the
CEP internal mount versus the Trifecta and the Mitroflow (LivaNova Group
Inc., Vancouver, Canada) external mounts.
We considered transcatheter aortic valve implantation in surgical aortic
valve replacement (TAVI in SAVR) for Case 2 due to a high risk of
reoperation. However, cardiogenic shock and loss of consciousness forced
emergency surgery and precluded TAVI in SAVR due to time constraints.
Also, in such cases, the valve area after TAVI in SAVR may be
constricted beyond the initial label size and this possibly smaller area
could induce high postprocedural gradients or ostial coronary
obstruction. Therefore, although Trifecta valves have an excellent
size-to-hemodynamic performance ratio, these smaller valves may increase
the difficulty of TAVI in SAVR. (9)
Conclusion:
Trifecta valves from any generation may suffer catastrophic SVD with
tears on two or more leaflets that cause severe heart failure and
require urgent surgery. This durability problem necessitates extreme
long-term vigilance after AVR and a re-evaluation of the utility and
durability of externally mounted valves.
References:
1. Bourguignon T, Bouquiaux-Stablo AL, Candolfi P, et al. Very long-term
outcomes of the Carpentier-Edwards Perimount Valve in aortic position.
Ann Thorac Surg 2015; 99: 831–7.
2.Minakata K, Tanaka S, Okawa Y, et al. Long-term outcome of the
Carpentier-Edwards Pericardial Valve in the aortic position in Japanese
Patients. Circ J 2014; 78: 882–889.
3.Phan K, Ha H, Phan S, et al. Early hemodynamic performance of the
third generation St Jude Trifecta aortic prosthesis: A systematic review
and meta-analysis. J Thorac Cardiovasc Surg. 2015; 149: 1567-1575.e1-
4.Youngue C, Lopez DC, Soltesz EG, et al. Durability and performance of
2298 Trifecta Aortic Valve Prostheses: A prospensity-matched Analysis.
Ann Thorac Surg. 2021; 111; 1198-206.
5.Hamamoto M, Kobayashi T, Ozawa M, Yoshimura K. Pure cusp tear of
Trifecta bioprosthesis 2 years after aortic valve replacement. Ann
Thorac Cardiovasc Surg. 2017; 23: 157-160.
6.Kaneyuki D, Nakajima H, Asakura T, et al. Early first-generation
Trifecta Valve failure: A case series and a review of the literature.
Ann Thorac Surg 2020; 109: 86-93.
7.Reyes G, Monguio E, Gomez-Marino MA, et al. Trifecta bioprosthesis
sudden-onset three-leaflet detachment. Ann Thorac Surg. 2021; e127-e128.
8.Vriesendorp M, de Lind van Wijngaarden RAF, Rao V, Moront MG, et al.
An in vitro comparison of internally versus externally mounted leaflets
in surgical aortic bioprosthesis. Interact Cardiovasc Thorac Surg. 2020;
30: 417– 423.
9.Dvir D, Webb JG, Bleiziffer S, et. al. Transcatheter aortic valve
implantation in failed bioprosthetic surgical valves. JAMA 2014; 312:
162–170.
Figure Legends
Figure1. Two leaflet tears at the bottom of the left coronary cusp and
at the parastent part of the non-coronary cusp. (yellow arrows)
Figure2. Chest X-ray showing bilateral pulmonary congestion.
Figure3. Two leaflet detachments existed at the bottom of the left
coronary cusp and parastent of the non-coronary cusp. (yellow arrows)
Abbreviations.
AS; Aortic stenosis
AR; Aortic regurgitation
LCC; Left coronary cusp
NCC; Non-coronary cusp
SVD; Structural valve deterioration